In reading the regs as it pertains to the new and improved attempt at UR mandates, it echoes the previous timeframe mandates. It also gives the adjusters the opportunity to defer based on liability issues.

What I don't see in the UR/IMR process, is the risk or potential outcome if those timeframes are not met. Scenario: DWC RFA is faxed. (a)there is no response or (b) the response is outside of the (5) business days for pre-auth or (30) days for retro. The service or goods are provided per the recommendation of the treating physician. Payment is never received with an EOB denying paymnet for lack of authorization (and thus initiating the IBR process). Regarding the treatment itself, do the findings of Sandhagen still aplly, where if the timeframes are not met, the treatment is in effect authorized since any UR findings not within the mandated time would be inadmissable and subsequently that was the IC opportunity to dispute the reasonableness/necessity of the treatment? Or do they now get a second bite of the apple and can force the IMR with the hopes that they get a favorable decision? In the latter, it seems that there is even less incentive for IC's to respond to requests or to spend their dimes on UR.

We, too, have a similar scenario. Patient burned, had treatment elsewhere, then was referred to us by occupational medical group where he was treating. We contacted adjuster at the TPA, who authorized consult. Burn needs grafting. We sent a detailed narrative PR-2 with an RFA, but now, two weeks later, we have no response. After the first week, I called and spoke with adjuster, who said that because it's going to cost so much they have to think about it!!!!! Now it's been two weeks, and the poor guy is still doing dressing changes. This is not life-threatening, but he will have a much higher risk of scarring and need for scar revision down the road, and in the meantime, he cannot return to work because of risk of infection, which grows every day. That has all been explained to the adjuster. Patient so far is not represented. What can we do to shake a response loose - either yay or nay -- so we can take the next step? And what is the next step if they decline?

Although not unusual, this is a horrid situation for this particular IW.

Being as your doc was approved by the TPA for a consult, I assume the referring physician at the occmed group is the PTP. (BTW, I hope that you got that consult approval from the adjuster at the TPA in writing.)

The consulting doc at your facility should have submitted a DFR (DLSR Form 5021), rather than a PR-2, along with the RFA --- not that this would have resulted in a different outcome.

Perhaps the adjuster at the TPA is hanging his/her hat on the fact the RFA was submitted by a consulting physician, rather than the PTP.

Considering the seriousness of the situation, with scarring and possible risk of infection absent the graft, if I were in your shoes, I would get the referring PTP to submit (via fax) a PR-2 along with your RFA, on an expedited basis. Perhaps this will result in some action.

You can also contact the Audit Unit for the LA area and complain verbally (213-620-2312), followed up by a written complaint sent via fax. This will not result in the adjuster changing his/her mindset about the expense, but it might just result in call to the TPA's adjuster from the Audit Unit, which will ensure a response to you or the PTP from the adjuster, ASAP.

(I still consider the Audit Unit to be a toothless tiger. Why? Well, LC 5814.6 has been in existence for almost 9 years --- but I have yet to see that bell rung, and there are many many ICs and TPAs who have suffered from more than two LC 5814 penalties that have become final. Thus, I believe that the Audit Unit is handling the ICs and TPAs with kid gloves.)

Gee whiz, what a PITA (Pain In The A**) this system has become. I'm sure glad I ceased accepting IWs 1/1/2005.

As a CYA move for the future, ensure that when you receive written "certification" from UR, that you follow-up and also obtain a written authorization from the adjuster. (Although with your facility's specialty, it is doubtful that a body part is accepted or denied, but for those in other specialties, a "certification" from UR is not a guarantee of payment, as the adjuster can object that although the UR "certification" has resolved the medically necessary issue, there may be a nature and extent, or body part issue.)